BRITISH COLUMBIA MEDICAL ASSOCIATION Hypertension – Detection, Diagnosis and Management Eective Date: February 15, 2008 Scope This guideline ocuses on the detection, diagnosis and management ohypertension (HT) in non- pregnant adults (age 19 years and older). Hypertension in each category is dened by an elevation othe systolic or diastolic threshold or both. Part I: DetectIonanD DIagnosIsBlood Pressure Assessment A baseline blood pressure (BP) should be established in all adults and reassessed periodically, commensurate with age and the presence oother risk actors. 1 Details oproper technique and equipment are included in Appendix A. Blood pressure monitoring should be rigorous in those patients who: • Have known or newly detected elevated BP • Have cardiovascular target organ damage * • Have other risk actors • Are receiving antihypertensive therapy * T arget organ damage includes: ce rebrovascular disease, coronary heart d isease (C HD), let ventricularhypertrophy (LVH ), chronic kidney disease (CKD), peripheral vascular disease and hypertensive retinopathy. Algorithm or the Detection and Diagnosis oHypertension (see Algorithm 1) Investigations and Risk Assessment • Urinalysis • Blood chemistry (potassium, sodium, creatinine/estimated glomerular ltration rate [eGFR]) • Fasting blood glucose • Fasting total c holesterol, high-density lipoprotein (HDL) c holesterol, low-density lipoprotein (LDL) cholesterol, triglycerides • Standard 12 lead electrocar diogram (ECG) • Microalbuminuria** (albumin/creatinine ratio [ACR]) 2,3 • Framingham risk assess ment (10-yea r CHD risk) (Appendix B) or UKPDS risk assessment iT ype II Diabetes (DM). See Diabetes Care at www.BCGuidelines.ca ** Detection omicroalbuminuria as an indicator okidney damage may be helpul when choosing a management strategy or hypertension. Currently , there is some evidence showing that angiotensin converting enzyme inhibitors (ACEI) do improve cardiovascular outcomes or patients with microalbuminuria. 3
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blood glucose; asting total cholesterol; high-density lipoprotein; low-density lipoprotein; triglycerides;
standard 12 lead electrocardiogram; microalbuminuria (albumin/creatinine ratio); Framingham risk
assessment (10-year CHD risk) or UKPDS risk assessment i Type II Diabetes.
Note: 24-hour ambulatory blood pressure measurement may provide inormation on white-coat hypertension and m
also be helpul in assessing patients with apparent drug resistance, hypotensive symptoms with
antihypertensive medications, episodic hypertension and autonomic dysunction. 4
Algorithm 1: Detection and diagnosis o hypertension
• Avg. BP ≥ 160/100 or• BP < 160/100 with DM, CKD, LVH or vascular
dementia or• CHD risk ≥ 20% over 10 years
Detection o elevated blood pressure* (≥140/90)
VISIT 1 Hypertension-specifc visit
Average (avg.) BP ≥140/90
I diastolic BP>130 orBP > 180/110 with signs/ symptoms (papilloedema,retinal hemorrhage), then
rgent treatment
Not hypertensive, reviewas indicated (age, risk)
Diagnosis o hypertension confrmed(Avg. BP ≥ 140/90 on three separate occassions)
Oer pharmacologic treatment withliestyle management and reassess regularly
Not hypertensive, reviewas indicated (age, risk)
Oer lietyle managmentand reassess regularly
I liestyle managmentinsufcient
(i.e., Avg. BP ≥ 140/90)
NO
NO
NO
VISIT 2
VISIT 3
YES
• Oer liestyle managment• Assess urther or hypertension (ofce or sel/home BP monitoring)**• Oer investigations to assess target organ damage and CHD risk***• Perorm physical exam
H ypertension – Detection, Diagnosis anD M anageMent DiagnosticCode: 401
BP READING INDICATION
< 140/90 1,4 No co-morbid conditions
≤ 130/80 1,4,6 Diabetes, renal disease or other target organ damage
< 160 systolic 1 Isolated systolic hypertension
Part II: ManageMent
A fow sheet is included in this guideline (Appendix D) to help acilitate care or your hypertensive
patients.
The Framingham Risk Assessment Chart (Appendix B) is designed to estimate 10-year coronary heart
disease (CHD) risk in adults who do not have heart disease or diabetes. For the purpose o this
guideline, CHD risk is used as a proxy or cardiovascular disease risk. The risk o stroke isapproximately 25% o CHD risk.5 The risk actors included in the Framingham calculation are: gender,
age, total cholesterol, HDL cholesterol, systolic blood pressure, treatment or hypertension and
cigarette smoking.
The Framingham Risk Assessment Chart is a useul tool or estimating CHD risk in hypertensive
patients, and may help inorm your treatment decisions.
Blood Pressure Readings and the Management o Hypertension
The management o essential hypertension requires patient liestyle management and/or therapeutic
intervention to work towards the ollowing blood pressure readings:
Table 1: Desirable blood pressure readings* † ‡
* The benefts o initiating antihypertensive therapy when mild to moderate hypertension is frst diagnosed ater
the age o 80 years are still uncertain.7 Treatment can be continued with caution in previously treated patients
ater the age o 80 years.
† The risk o a systolic blood pressure in the range o 140 to 160 and/or a diastolic blood pressure in the range
o 90 to 100, in the absence o target organ damage or other risk actors, is small and may not outweigh the
potential harms o pharmacologic treatment in all patients.
‡ Exercise caution in patients who have a diastolic BP close to 60, and regardless o BP, reassess the need or
treatment i hypotensive symptoms exist.
Review patient at monthly intervals until BP is in the desired range or two consecutive visits. Then
review every 3-6 months (as long as the patient remains stable).
At each visit:
• Measure blood pressure
• Reinorce benets o a healthy liestyle• Conrm that medications are taken appropriately
• Review the patient’s knowledge o their condition and their treatment
• Establish the minimum dose o medication required to achieve the desired BP
H ypertension – Detection, Diagnosis anD M anageMent4
DiagnosticCode: 401
Liestyle Management 1,4
As a diagnosis is being established, provide adequate explanation and support to patients so that they
clearly understand the nature and signicance o this condition, and that they have the primary
responsibility or the management o their blood pressure. Provide patients with inormation on
available community support, such as those oered by the Heart and Stroke Foundation, including
sel-management courses (see Hypertension Patient Guide).
Oer and review the ollowing liestyle recommendations at each visit:
• Smoking cessation: Complete cessation o smoking and avoidance o exposure to second hand
smoke is recommended. For assistance to quit, reer patients to QuitNow Services at
1 877 455-2233 (toll-ree in BC; available 24/7/365) and at www.quitnow.ca to obtain sel-help
materials.
• Physical activity: All people should be prescribed 30-60 minutes o moderate intensity dynamic
activity 4-7 days per week (dynamic activity includes: walking 3 km [2 miles] in 30 minutes once
per day or walking 1.5 km [1 mile] in 15 minutes two times per day, jogging, cycling or swimming).
Recommend getting a pedometer or immediate positive eedback.
• Weight reduction: Maintenance o a healthy body weight (body mass index [BMI]
18.5-24.9 kg/m2, waist circumerence < 102 cm [40"] or men and < 88 cm [35"] or women) is
recommended or everyone. All overweight hypertensive individuals should be advised to lose
weight. Weight loss strategies should be long-term and employ a multidisciplinary approach that
includes dietary education, increased physical activity and behavioural intervention.
• Dietary recommendations: Hypertensive individuals and normotensive individuals at increased
risk o developing hypertension should consume a diet that emphasizes ruits, vegetables, low-at
dairy products, bre, whole grains, and protein sources that are reduced in saturated ats and
cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet) (see Appendix E). In addition,
reduced consumption o trans-ats and increased consumption o sh high in omega 3 atty acidsreduces cardiovascular risk.
• Reduce salt intake: In addition to a well-balanced diet, a reduced dietary sodium intake o≤ 1,500 milligrams per day (approximately 1 tsp o table salt) is recommended or individuals with
hypertension. Advise patients about the "hidden" salt content o processed oods, such as
lunchmeat, canned soups and pasta.
• Alcohol consumption: Alcohol consumption should be limited to two drinks or less per day and
consumption should not exceed 14 standard drinks per week or men and 9 standard drinks per
week or women. A standard drink is dened as:
• 1 can (341 mL) o 5% beer or• 1 glass (150 mL) o 12% wine or
• 1.5 oz (45 mL) o 40% spirits
• Potassium, calcium and magnesium intake: Supplementation o potassium, calcium and
magnesium is not recommended or the prevention or treatment o hypertension.
Note: - Beta-blockers may no longer be a rst-line treatment option (with some exceptions)9,10
- Long-acting DHP-CCBs are a preerred second-line treatment option or patients at risk or,
or with a history o, stroke
- Alpha-blockers are not a rst-line treatment option
Consideration should also be given to the addition o low-dose ASA therapy in hypertensive patientswith a Framingham risk score o ≥ 20% who are between 50 and 70 years-o-age. Avoid using ASA in
patients with a history o hemorrhagic stroke. Blood pressure must be well controlled.11,12
3. First-line treatment for hypertension complicated by co-morbid conditions1
It is important to control co-morbid conditions optimally when managing hypertension. Pharmacologic
treatment must be chosen with even more care in these individuals. The ollowing table lists
recommended medications or consideration when individualizing antihypertensive drug therapy.
See Appendix F or a list o commonly prescribed antihypertensive medications in each class.
The investigation and management o secondary causes o hypertension is beyond the scope o thisguideline. Please consult current medical texts or investigation and management advice, or consider
reerral to an appropriate specialist. For some examples o secondary causes o hypertension, reer to
Appendix G.
Rationale
The ollowing subsections include a brie overview o the literature used to generate recommendations
or this guideline. The nal subsection provides the methodology used or obtaining evidence and
describes the types o evidence used throughout this guideline.
Hypertension (HT) remains a major public health issue in Canada. Although the diagnosis and
treatment o HT appears simple, this disease remains poorly managed; or example, it is estimated
that only 50% o Canadians with hypertension are aware o their diagnosis and that only 16% oCanadians with hypertension have adequate BP control.1
Combined, heart disease and stroke are the leading cause o death, accounting or one in three deaths
in BC.13 Hypertension is a signicant and controllable risk actor or heart disease, stroke, heart ailure,
renal disease and recurrent cardiovascular events.6 Hypertension is also the most common indication
in Canada or visits by adults to physicians.14
The benets o lowering blood pressure in certain settings with liestyle changes and certain drugs
have been well documented. Reductions in mortality,6,8,15 cardiovascular events,4,8,15,16 let ventricular
hypertrophy,4 stroke and myocardial inarction,8,15,17 dementia,18,19 deterioration o renal unction,4,15,20
renal ailure20 and incidence o diabetes15 have all been associated with successul treatment o
hypertension.Evidence: Evidence was obtained through a systematic review o peer-reviewed literature (up to May,
2007) using the databases MEDLINE, PubMed, EBSCO, Ovid, and the Cochrane Collaboration’s
Database or Systematic Reviews. Clinical practice guidelines rom other jurisdictions or the
prevention and management o hypertension, diabetes, chronic kidney disease, dyslipidemia,
congestive heart ailure, cerebrovascular disease and overweight/obesity were also reviewed (up
to May 2007). Recommendations are based on large, randomized controlled trials (RCTs) wherever
possible. Liestyle recommendations are based on large, prospective cohort trials.
H ypertension – Detection, Diagnosis anD M anageMent8
DiagnosticCode: 401
Reerences
1. Canadian Hypertension Education Program. 2007 CHEP recommendations or the management o
hypertension. 2007. www.hypertension.ca/chep/
2. Jensen J, Feldt-Rasmussen B, Strandgaard S, et al. Arterial hypertension, microalbuminuria, and
risk o ischemic heart disease. Hypertension 2000;35:898-903.
3. Atthobari J, Asselbergs FW, Boersma C, et al. Cost-eectiveness o screening or albuminuria
with subsequent osinopril treatment to prevent cardiovascular events: A pharmacoeconomicanalysis linked to the Prevention o REnal and Vascular ENdstage Disease (PREVEND) study and
the Prevention o REnal and Vascular ENdstage Disease Intervention Trial (PREVEND IT). Clin Ther
2006;28(3):432-444.
4. Chobanian AV, Bakris GL, Black HR, et al. The seventh report o the Joint National Committee on
prevention, detection, evaluation, and treatment o high blood pressure: The JNC 7 Report. JAMA
2003;289(19):2560.
5. Wol PA, D’Agostino RB, Belanger AJ, et al. Probability o stroke: A risk prole rom the
Framingham study. Stroke 1991:22(3):312-318.
6. Whitworth JA. 2003 World Health Organization (WHO)/International Society o Hypertension (ISH)
statement on management o hypertension. J Hypertens 2003;21(11):1983-1992.
7. Elliott WJ. Management o hypertension in the very elderly patient. Hypertension 2004;44:800-804.8. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various antihypertensive
therapies used as rst-line agents: A network meta-analysis. JAMA 2003;289(19):2534.
9. Wiysonge CS, Bradley H, Mayosi BM, et al. Beta-blockers or hypertension. Cochrane Database
Syst Rev 2007.
10. National Collaborating Centre or Chronic Conditions. Hypertension: management o hypertension
in adults in primary care: partial update. London: Royal College o Physicians, 2006.
11. Baigent C. Aspirin or everyone older than 50? Against. BMJ 2005;330(7505):1442-1443.
12. Ridker PM, Buring JE. Aspirin in the prevention o cardiovascular disease in women. N Engl J Med
2005;352(26):2752-2752.
13. British Columbia Vital Statistics Agency. Selected vital statistics and health status indicators. One
hundred and thirty-ourth Annual Report. 2005.14. Kaplan NM. Guidelines or the management o hypertension. Can J Cardiol 2000;16(9):1147-1152.
15. Dahlö B, Sever PS, Poulter NR, et al. Prevention o cardiovascular events with an antihypertensive
regimen o amlodipine adding perindopril as required versus atenolol adding bendrofumethiazide
as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm
(ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005;366(9489):895-906.
16. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme
inhibitor or calcium channel blocker versus diuretic: The Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288(23):2981.
17. Law MR, Wald NJ, Morris JK, et al. Value o low dose combination treatment with blood pressure
lowering drugs: analysis o 354 randomised trials. BMJ 2003;326(7404):1427.
18. Forette F, Seux M, Staessen JA, et al. Prevention o dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet 1998;352(9137):1347-1351.
19. Tzourio C, Anderson C, Chapman N, et al. Eects o blood pressure lowering with perindopril and
indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease.
Arch Intern Med 2003;163(9):1069-1075.
20. Casas JP, Chua W, Loukogeorgakis S, et al. Eect o inhibitors o the renin-angiotensin system
and other antihypertensive drugs on renal outcomes: systematic review and meta-analysis. Lancet
Blood pressure is not constant. Many actors will cause your blood pressure to vary signicantly over
the course o the day, such as exertion, stress and medications. Since most people tend to have higher
blood pressure in the doctor’s oce, using only oce readings may overestimate both your overall
blood pressure and your need or medication.
Checking your blood pressure outside o the doctor’s oce will greatly assist your doctor in determiningi a problem truly exists and to evaluate the eectiveness o any medication, should that prove
necessary. When using the home blood pressure monitor you should be comortably sitting upright,
with back support, and with the muscles o your arms and legs relaxed.
Once you have applied the cu to your arm, distract yoursel by watching TV or reading, or a couple o
minutes, beore you activate it. Write the blood pressure and pulse (heart rate) into the chart above. I
you have the time and the inclination, average out the data you have collected e.g. 144/92,
153/88. 137/77 and 150/95 in the morning column give a morning average o 146/88 since
(144+153+137+150)/4=146 and since (92+88+77+95)/4=88.
* Reproduced with permission rom Dr. Scott Garrison, M.D.
Note: • Long-acting DHP-CCB are preerred 2nd line treatment or patients at risk or, or with a history
o, stroke
• Beta blockers may no longer be a rst line treatment option, with some exceptions
• Alpha blockers are not a 1st line treatment option
Consider addition o low-dose ASA therapy i Framingham risk score is ≥ 20% and patient is between 50 to 70
years-o-age. Avoid using ASA in patients with a history o hemorrhagic stroke. Blood pressure must be well
controlled.
See hypertension guideline or pharmacologic management i co-morbid conditions exist.
Pharmacologic Treatment without Co-morbid Conditions
Suggestions or the ollowing liestyle changes should be oered and reviewed at each visit:
Smoking cessationRecommend complete cessation o smoking and exposure to second hand smoke.
QuitNow Services: 1 877 455-2233 (toll-ree in BC; available 24/7/365) www.quitnow.ca
Physical activity
Prescribe 30-60 minutes o moderate intensity dynamic activity (such as walking 3 km [2 miles] in 30 minutesonce per day, or 1.5 km [1 mile] in 15 minutes two times per day, jogging, cycling or swimming) 4-7 days per
week. Recommend getting a pedometer or immediate positive eedback.
Weight reduction All overweight patients with hypertension should be advised to lose weight. Weight loss strategies should be
long-term and employ a multidisciplinary approach that includes dietary education, increased physical activity,
and behavioural intervention. Target: body mass index (BMI) 18.5-24.9 kg/m2, waist circumerence <102 cm [40"]
or men and <88 cm [35"] or women.
Dietary recommendations Advise a diet high in ruits, vegetables, low-at dairy products, bre, whole grains and protein sources reduced in
saturated ats and cholesterol (Dietary Approaches to Stop Hypertension [DASH) diet]. Reduce consumption o
trans-ats and increase intake o sh high in omega 3 atty acids.
Reduce salt intakeRecommend reduced dietary sodium intake o ≤ 1,500 milligrams per day (approximately 1 tsp o table salt).
Alcohol consumption
Limit to two drinks or less per day, and consumption should not exceed 14 standard drinks per week or men
and 9 standard drinks per week or women.
Potassium, calcium and magnesium intake
Supplementation o potassium, calcium and magnesium is not recommended or the prevention or treatment o
Hypertension is the medical term or high blood pressure. Blood pressure reers to the orce o
blood against the blood vessel walls. Normally a person’s blood pressure rises and alls during the
day. However, when blood pressure constantly stays higher than normal (140/90 mm Hg or higher)
a person is considered to have hypertension.
What causes hypertension?
For about 90-95% o people with mildly elevated blood pressure, inactive liestyle, smoking,excess abdominal weight, a atty diet, alcohol consumption and stress contribute to the condition.
For the other 5-10% o people, there may be a serious underlying cause o high blood pressure
that requires urgent medical attention.
Risk actors or developing hypertension that you can control include liestyle choices such as:
• Smoking
• Physical inactivity
• Excess weight (esp. around the waist)
• High-at diet
• Excessive salt intake
• Excessive alcohol consumption
Risk actors or developing hypertension that you cannot change are:
• Family history o hypertension, heart disease or stroke
• Age 45 years or older or men; 55 years or older or women
• Ethnicity (high blood pressure is more common in individuals o South Asian, First Nations/
Aboriginal, Inuit or Arican descent)
How do I know if I have high blood pressure?
Unortunately, a person with high blood pressure usually does not see or eel any obvious symptoms
o hypertension. That is why you should have your blood pressure checked by a health care
proessional. Hypertension is conrmed i blood pressure alls within the ollowing 3 stages o severity:
Systolic Blood Pressure Diastolic Blood Pressure
Mild 140 to 159 mm Hg 90 to 99 mm Hg
Moderate 160 to 179 mm Hg 100 to 109 mm Hg
Severe 180 mm Hg or higher 110 mm Hg or higher
Hypertension – Detection, Diagnosis and Management
Hypertension can lead to a number o potentially lie-threatening conditions i it is not controlled
or treated. The higher your blood pressure, the greater your risk o developing the ollowing
problems:
• Heart disease: Hypertension is a major risk actor or heart attack, and the number one risk
actor or congestive heart ailure.
• Stroke: Hypertension is the leading risk actor or stroke. Very high blood pressure can cause
a weakened blood vessel to rupture and bleed into the brain. A blood clot blocking a narrowed
artery can also cause a stroke.
• Chronic kidney disease (CKD): Hypertension is the second leading cause o kidney disease
(diabetes is its leading cause) and kidney ailure requiring dialysis or transplant.
• Retinopathy (eye damage): Hypertension can cause small blood vessels in the eye to burst or
bleed. This can lead to blurred vision or even blindness.
• Peripheral vascular disease (PVD): Hypertension is an important risk actor or PVD, which is
a narrowing and hardening o arteries that leads to restricted blood fow to the legs, arms,
stomach or kidneys.
• Impotence or erectile dysunction: Hypertension is a common cause o erectile dysunction.
Hypertension can lead to changes in the blood vessels that may prevent blood rom lling the
penis or rom remaining there long enough to maintain an erection.
How can I control my blood pressure?
You can reduce your blood pressure and control hypertension. The ollowing liestyle choices can
help you prevent and control hypertension. See Figure 1 or the relative importance o these
measures.
✓ Stop smoking
Smoking is a key risk actor or hypertension, heart attack and stroke. Call QuitNow Services
at 1 877 455-2233 (toll-ree in BC, 24/7/365) or assistance to quit, or obtain sel-help
materials rom their Web site at www.quitnow.ca.
✓ Eercise regularlyExercise is one o the best things you can do or your health and blood pressure. Build physical
activity into your daily routine by walking wherever and whenever you can, stretching and
moving around requently, taking the stairs instead o the elevator and participating in
activities that you enjoy. Work towards incorporating at least 30-60 minutes o moderate
activity 4-7 days per week (moderate activity includes: walking 3 km [2 miles] in 30 minutes
once per day, or 1.5 km [1 mile] in 15 minutes two times per day, jogging, cycling or swimming).
The Web site www.actnowbc.ca contains advice on how to increase your physical activity
and reduce your weight.
✓ Maintain a healthy body weight
A body-mass index (BMI) greater than 27 or a waist circumerence greater than 102 cm
(40 inches) or men and 88 cm (35 inches) or women, is associated with an increased risk ocardiovascular disease. To accurately measure your waist, place the tape measure between your
hip bone and rib cage (near the belly button). Losing weight through a combination o a
healthul diet and increased physical activity will help lower your blood pressure and lower your
risk o a heart attack, stroke, kidney disease and type II diabetes.
✓ Eat a well balanced diet
Eat oods that are low in saturated at, trans-at and cholesterol (< 300 mg/day) and high in
bre. Recent studies also show a major benet rom consuming vegetables, ruits, sh
(> 2 servings per week) and low-at dairy products, as well as limiting salt intake.
The DASH diet (Web site: www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pd) and
Mediterranean diet have been shown to lower blood pressure and reduce cardiovascular risk. Eating
well doesn’t have to mean giving up the oods you love. It simply means choosing wisely rom a
variety o oods and choosing lower at and less salty oods more oten. For more inormation,
call Dial-a-Dietitian toll ree at 1 800 667-3438 or visit www.dialadietitian.org.
✓ Reduce salt intake
Reducing salt intake can prevent hypertension and lower elevated blood pressure. In addition toa well balanced diet, a reduced dietary sodium intake o 1500 milligrams per day (approximately
1 tsp o table salt) is recommended or people with hypertension. Call Dial-a-Dietitian at
1 800 667-3438 or visit www.dialadietitian.org to learn about how to manage your diet and
reduce your salt intake to control hypertension. Inormation on reducing salt intake can also be
ound on the Heart and Stroke Foundation’s Web site at www.heartandstroke.ca/bp/.
✓ Limit alcohol consumption
Moderate alcohol consumption or most adults is no more than 1-2 standard drinks per day to a
weekly maximum o 14 drinks or men and 9 drinks or women. A standard drink is dened as:
• 1 can (341 mL) o 5% beer or
• 1 glass (150 mL) o 12% wine or
• 1.5 oz (45 mL) o 40% spirits
✓ Medications
Medications can be very eective in keeping your hypertension under control. Discuss the
benets and risks o taking medications or your hypertension with your doctor. Take
medications only as prescribed and at approximately the same time o day each day. I you are
on antihypertensive medication(s), avoid getting up quickly rom a seated or lying position, as
this can cause dizziness and lead to alls.
Additional liestyle management inormation, specically on healthy eating, physical activity and
smoking cessation, may be ound at www.actnowbc.ca. ActNowBC recommends 0/5/30 as
ollows:
0 Smoking: Complete avoidance o tobacco smoke
5 Servings o ruits and vegetables per day (minimum)
30 Minutes o moderate-intensity activity per day (minimum)
compared to prescription medication management (BP control, statins) or patients without heart
disease.
4
Reerences
1. Walsh JME, Pignone M. Drug treatment o hyperlipidemia in women. JAMA 2004;291(18):2243- 2252.
2. Studer M, Briel M, Leimenstoll B, et al. Eect o dierent antilipidemic agents and diets on mortality: A
systematic review. Arch Intern Med 2005;165(7):725-730.3. Trichopoulou A, Costacou T, Bamia C, et al. Adherence to a Mediterranean diet and survival in a
Greek population. N Engl J Med 2003;348(26):2599-2608.
4. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various antihypertensive
therapies used as rst-line agents: A network meta-analysis. JAMA 2003;289(19):2534.
5. Manson JE, Greenland P, LaCroix AZ, et al. Walking compared with vigorous exercise or the
prevention o cardiovascular events in women. N Engl J Med 2002;347(10):716-725.
6. Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years' observations on male
British doctors. J Epidemiol Community Health 2004;58(11):930.
Internet Resources
The Guidelines and Protocols Web site (www.BCGuidelines.ca) has more detailed inormation about themanagement o diseases such as hypertension and diabetes.
The BC HealthGuide Online (Web site: www.bchealthguide.org search word: high blood pressure)
provides detailed inormation on managing hypertension.
The Heart and Stroke Foundation of Canada (Web site: www.heartandstroke.ca) oers excellent materials or
the control o liestyle actors that contribute to hypertension, heart disease, stroke and kidney disease. This
includes public recommendations or the control o high blood pressure, the Blood Pressure Action Plan™ (an
online e-tool to help you control your blood pressure), a body mass index calculator, a risk actor calculator and